Liver transplantation is a surgical procedure which replaces the irreversibly sick liver of an individual with a healthy liver from a donor.
Given the huge demand, liver transplant candidates are chosen after a long series of specific tests. If at the end of the investigation the individual is fit for the intervention, he is placed on a waiting list and called as soon as possible.
The surgery is very long and requires a team of experienced doctors. If no complications arise, such as rejection, the patient can gradually return to a normal life.
What is liver transplantation?
Liver transplantation is the surgical procedure which replaces a liver that is irremediably damaged with another healthy one, coming from a blood-compatible donor .
The donor is usually a recently deceased person, but if the conditions are met, he can also be a living individual. In fact, the liver is an extraordinary organ, capable of self-healing even after its partial removal.
Before receiving a new liver, an individual must undergo several tests aimed at assessing whether there are appropriate conditions for a transplant. If a patient is considered suitable, he is placed on a waiting list, in which there are other people in his same condition.
FUNCTIONS OF A HEALTHY LIVER
The liver is one of the most complex organs of the human body; not surprisingly, it carries out a very high number of functions, many of which are fundamental for life.
The most important tasks include:
- The production of coagulation factors, to stop blood loss
- The regulation of cholesterol levels in the blood
- Production of essential proteins and hormones
- The "cleansing" of blood, from toxins and infectious agents
- Supply the body with energy when it is in deficit
HOW MUCH IS THE LIVER TRANSPLANT?
The number of people who would need a liver transplant is high and significantly higher than the number of existing donors.
According to some statistical data of 2009, in Italy the number of liver transplants performed was 1059, but the patients on the waiting list were 1481. From 1992 to 2009, still in Italy, the transplant recipients were 12759.
The survival rate five years after transplantation is 75-80%.
The most common cause of liver transplantation is cirrhosis caused by hepatitis C (see the next chapter).
When is it put into practice?
The liver, for various reasons, can be deeply damaged and permanently lose its function. This process is known as liver failure .
Individuals with severe liver failure are the best candidates for a liver transplant, as this is the only effective treatment to save their lives. But what are the causes of liver failure and, indirectly, of liver transplantation?
CAUSES OF LACK OF HEALTH
Severe hepatic failure may have different origins.
The main and even most common cause is cirrhosis (or liver cirrhosis ), which is the process in which liver cells ( hepatocytes ) die and are replaced by scar or fibrous tissue.
Liver cirrhosis is usually caused by:
- Viral infections ( hepatitis C and hepatitis B ),
- Alcohol abuse
- Autoimmune liver disease
- Abnormal fat accumulation in the liver
Among the less common causes, instead, we must mention:
- Cystic fibrosis
- Liver cancer
- hemochromatosis
- Biliary atresia
- Wilson's disease
- Sclerosing cholangitis
ACUTE AND CHRONIC HEALTH INSUFFICIENCY
The speed with which symptoms of liver failure appear distinguishes this pathological condition in:
- Acute liver failure . The symptomatology appears suddenly, evolves over a very short time and can have dramatic effects. It is a rare event, which usually occurs due to poisoning with paracetamol (a common analgesic) or other substances (eg poisoning by A. Phalloides).
- Chronic liver failure . Disorders develop slowly and can take several months, if not years, to seriously damage the liver. Between the two, it is the most frequent form of liver failure.
IMPORTANCE OF THE LIVER TRANSPLANTATION
Unlike the heart, kidneys and lungs, there is no artificial organ or mechanical device (such as kidney dialysis) that can replace a malfunctioning liver. The only possible solution, when liver damage is deep and irreparable, is human organ transplantation. This explains several aspects: not only the difficulties in recovering a body compatible with the patient, but also the enormous demand, waiting times and the procedure to follow to return to the waiting lists.
Risks of the transaction
Liver transplantation is a very delicate operation and not without complications.
Most problems arise due to the continuous and mandatory intake of immunosuppressive drugs ; these are administered with the idea that, by weakening the immune system, the transplanted organ is not attacked and "treated" by the immune system as something foreign to the body.
A list of possible complications, which a liver transplant can meet, is as follows:
- Rejection or failure of the transplant
- Viral and fungal infections
- Thrombosis
- Biliary tract problems
- Diabetes
- Kidney failure
- Neoplasms of various types
- Post-transplant lymphoproliferative diseases
REPLACEMENT OR FAILURE OF THE TRANSPLANT
Transplant rejection and failure are two distinct but equally serious situations.
Rejection occurs when the immune system does not recognize the transplanted organ (in this case, the liver) and attacks it as if it were something foreign.
The word failure, on the other hand, refers to the operational failure of the organ, which does not work as it should have. In these situations, the cause is often a thrombosis in the hepatic artery or in the portal vein, which occurs after the operation.
The rejection, if it takes place, occurs after 7-14 days and refers approximately to 40% of cases (wide variability in the literature between the various cases).
Failure occurs when it occurs within a few hours and affects 10-15% of transplants.
Symptoms of rejection:
- High fever
- He retched
- Diarrhea
- Jaundice
- Dark urine
- itch
- I made clear
INFECTIONS
Fungal and viral infections are particularly frequent in liver transplants and not only. The cause is linked, as anticipated, to the intake of immunosuppressive drugs.
The fungal infections found are those supported by candidiasis (more frequent) or fungal pneumonia (very rare).
The most common viral infections, on the other hand, are those caused by cytomegalovirus ; these can be prevented by taking antibiotics for several months after the surgery.
KIDNEY FAILURE
Just as liver failure is the loss of liver function, so kidney failure is a drastic reduction in kidney capacity.
According to an English source, this situation occurs in a liver transplant every 5 and has, as a probable cause, the intake (once again) of immunosuppressive drugs.
Symptoms of renal failure:
- Fatigue
- Water retention (ie, swollen hands and feet)
- Shortness of breath
- Nausea
- Blood in the urine
CANCERS
Those who have undergone liver transplantation are more prone to cancers of the skin, cervix (in women) and lymphoid cells ( lymphoma ).
The most reliable cause seems to be linked to immunosuppressants, although some doubts remain.
It is estimated that skin cancers (above all, Kaposi's melanomas and sarcomas ) have a probability of onset twenty times higher than healthy non-transplanted individuals. For this reason, it is recommended that the patient avoid excessive exposure to the sun or artificial ultraviolet lights.
How to prepare for surgery
Unlike the availability of transplantable livers, the demand for interventions is enormous. For this reason, before being considered suitable for a liver transplant, an individual with liver problems undergoes a long series of targeted tests. If, at the end of these very rigorous checks, the patient has all the necessary characteristics, then he is placed on a waiting list together with others who, like him, have the same problems.
When his turn comes, he will be called by the transplant center, which performed the tests on him, and will be subjected to the operation.
HOW IS INSERTION IN THE WAITING LIST?
A transplant center is put in contact with a patient by the attending physician, who, after various tests, hypothesizes that there may be conditions for inclusion on the waiting list.
At that point, the patient will be visited by a team of doctors and experts (surgeons, hepatologists, nurses, social workers, etc.), who, only after a thorough analysis, will decide whether the transplant is the best solution.
The useful tests are numerous and of different types:
- Laboratory tests : first of all, blood and urine tests are performed. After that, it goes deeper, with cancer screening. These analyzes are used to establish the patient's state of health and whether this can withstand a liver transplant.
- Radiological examinations : they serve to further clarify the patient's state of health. Furthermore, an image of the liver and, in general, of the cavity where it resides, gives an idea of the size of the internal organs, placed in the immediate vicinity of the liver.
- Cardiac tests : a healthy cardiovascular system is an essential condition for receiving a new liver.
- Psychological and social evaluation : the first is to understand if the patient is mentally ready to receive a new liver and if he is aware of the importance of the intervention and the implications it includes. The second assesses whether family members and close friends of the patient are able to follow the latter if he needs help.
- Evaluation of any addictions : the patient's inclinations towards alcohol, drugs and smoking are evaluated. Those who are dependent or considered at risk are not placed on the waiting list.
If each of these assessments is positive (ie in favor of the intervention), then the patient will be placed on the waiting list.
In what situations are you excluded from the waiting list?
- Serious infectious diseases (if it is a passing disease, you can wait for it to recover and then propose yourself again for inclusion on the list)
- AIDS
- Severe heart and circulatory disorders
- Tumor in any part of the body
- Addiction to drugs, alcohol and smoking
- Being unable to take care of your health
- Absence of family or close friends able to follow the patient, should this need help
LOCATION IN THE WAITING LIST
There are more severe liver patients than others. The former, after the aforementioned checks, will be placed in a more advanced position than the latter.
The severity of a patient's liver failure can be marked with two different scores: the MELD (English acronym for Model for End-Stage Liver Disease ) and the Child-Pugh .
HOW LONG IS THE WAIT FOR A TRANSPLANT?
Waiting times for a liver transplant are variable (from weeks to months) and cannot be determined exactly. They mainly depend on:
- Blood group of the patient, for a speech of compatibility of blood. There are rarer blood groups than others and this has a significant impact on the availability of transplantable organs.
- Similar body size between donor and recipient. If weight and height coincide, it is likely that the internal organs are large equal.
- Position on the waiting list, established by the MILD and Child-Pugh scores.
THE CALL FROM THE TRANSPLANT CENTER
The call from the transplant center, which informs the patient of the organ's availability, can take place at any time of the day. For this reason, when you are on the waiting list, it is good to always be available to be able to respond to the call.
It is very important, once the communication is received, to abstain from eating and drinking, because, as we will see, general anesthesia is provided.
Procedure
Liver transplantation is a very delicate surgical operation, which for this reason must be performed under general anesthesia.
MEDICAL AND SPECIALIZED STAFF
The team of doctors and experts who perform the transplant, and follow the patient during the post-intervention stay, is made up of different figures, all equally important:
- Anesthesiologist
- Surgeon
- Nursing specialist in transplants
- Medical hepatologist
- Physiotherapist
- Psychologist
- Social worker
GENERAL ANESTHESIA
When it is said that an operation is performed under general anesthesia, it means that the patient is unconscious and does not feel pain at the time of the operation.
It is also quite common to practice intubation (ie the insertion of a tube in the mouth and up to the trachea), to allow the individual in treatment a correct and regular breathing.
To avoid complications due to general anesthesia, it is advisable to follow the instructions of the doctor, who is recommended, first of all, to abstain from food and drink.
LIVER TRANSPLANTATION FROM DEAD DONOR
Transplantation of a liver from a dead donor is performed as follows.
The surgeon first of all cuts into the patient's abdomen to gain access to the abdominal cavity; subsequently it isolates the diseased liver from the connections with the blood vessels and the biliary tract.
After this, he proceeds with the removal and replacement of the hepatic organ.
Finally, before closing the abdomen with different stitches, it re-establishes all the connections between the liver, blood vessels and bile ducts.
At the end of the intervention, the patient is kept under observation for several days.
What is split liver ?
The split liver, translated into Italian as " divided liver ", is a normal dead donor liver transplant, where, however, the liver to be implanted is divided into two: the larger part is destined for an adult recipient, while the longer part small is assigned to a young recipient or of small build.
TRANSPLANT OF LIVER FROM A LIVING DONOR
Liver transplantation from a living donor requires two consecutive surgical operations, the first on the donor and the second on the recipient.
Figure: liver with its blood vessels (arteries in red; veins in blue) and its bile ducts (in green).
The intervention on the donor involves the incision of the abdomen and the removal of one of the two lobes of the liver: the right lobe, which is larger, is reserved for adult patients or those of normal build, while the left lobe, which is smaller, is reserved for young patients (usually children) or small body size.
The intervention on the recipient is completely the same as that applied in the case of transplants from dead donors.
The lobes, both in the recipient and in the donor, grow very quickly: in fact, after a week from the transplant, the liver has already reached 85% of its original size.
The big advantage of a living donor transplant is that waiting times are significantly reduced. In fact, if there is blood group compatibility between two members of the same family (or even between two very close friends), the operation can be immediate.
HOW LONG IS THE INTERVENTION?
Some liver transplant operations can last up to 12 hours .
Recovery methods and times
Figure: the liver, left lobe and right lobe. In living donor transplantation, one of the two lobes is taken, depending on the recipient's body size.
At the end of the operation, the patient must spend a few days in intensive care, under strict medical supervision, to understand how the body reacts to the transplant.
If all goes well and without complications, the transplanted individual is admitted to a hospital ward for at least a couple of weeks. During this time, doctors and specialized staff will teach the patient how to take maximum care of their health and which drugs to take when they leave.
DRUGS
Immunosuppressant drug therapy starts immediately and lasts for the rest of life. At first the medical staff takes care of it, but afterwards the patient will have to take care of it: this explains why numerous tests are required, aimed at understanding whether a person is able to manage his own health or not.
In addition to immunosuppressive drugs, it is very likely that painkillers will also be administered in the first few days, as the operation is somewhat invasive.
Deepening: immunosuppressants
Immunosuppressants, by reducing the efficiency of the immune system, prevent the rejection of the transplanted liver. Although it is a risky therapy, as it exposes the patient to infections and other disorders (see the chapter dedicated to the risks of the operation), it is fundamental for the new organ not to be "treated" as an object foreign to the body. Especially in the beginning, when the risk of rejection is high, the doses of immunosuppressants are high. Any reduction in quantities is a choice that is up to the attending physician and is taken into consideration after two or three months.
The main pharmacological preparations are calcineurin inhibitors and corticosteroids .
PERIODICAL CHECKS
From the time the operation is completed and for the rest of life, a liver transplanted individual must undergo periodic checks, assessing his general state of health and that of the transplanted liver.
The checks consist mainly of blood tests.
RESULTS
Some important recommendations- Avoid contact with sick people, even if it is a simple flu
- To gradually resume physical activity
- It is absolutely forbidden to drink alcohol, smoke and take drugs
- Contact your doctor before taking any medication
- Undergo regular medical checks
- Avoid excessive exposure to ultraviolet rays from the sun
If no complications occur, the return to a normal life can take from 6 to 12 months. At the end of this long period, the patient can also return to work and exercise, provided that he continues to take immunosuppressants and takes care of his health.
The healing time could be longer if the patient's condition, before surgery, was very serious or if he had to wait a long time for the transplant.
From some Italian statistical surveys (whose results are very similar to those of other countries) it emerged that about 75% of people undergoing liver transplantation survive at least another 5 years after surgery.
